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ACEP COVID-19 Field Guide

Table of Contents

Telehealth and Tele-Triage

Triage

Contributing authors: Etch Shaheen, Michael Baker, Kevin Curtis, Aditi Joshi, Brian Skow, Jeffrey Davis, Alison Haddock, and Gerardine Villaneueva

HCWs are at an increased risk of contracting COVID-19. Frequent and close physical interactions among patients and HCWs contribute to this elevated risk of viral transmission. The critical shortage of personal protective equipment (PPE) that can limit this exposure is worsening, as PPE availability is limited by global supply chain challenges. Thus, reducing face-to-face contact, without compromising care, can reduce the rate at which the illness is acquired and decrease transmission in the health care community.

Although social distancing in the health care setting is difficult, current practices can be modified in the interim to accommodate our present needs. Patients needing evaluation for COVID-19 can remain in a waiting room or tent, where triage and initial workup are performed by QMPs such as physicians, NPs, and PAs that are either employed by the hospital or outsourced. Successful implementation is limited by legal and regulatory restrictions, safety, resources, technology, capacity, additional training, support from staff and leadership, and the culture of the organization; however, careful planning, training, and frequent re-evaluation of processes can lead to greater simplicity, flexibility, and efficiency with encounters. 

In terms of our current legal environment, the federal, state, and local governments have provided temporary flexibilities in regulations to conform to the changing needs of this pandemic. As of March 2020, CMS has broadened access to telehealth services under the president’s emergency declaration. Although temporary, maintaining access to care while limiting exposure can further reduce the rate of transmission or acquisition of COVID-19. Some hospitals have also implemented emergency privilege processes, modifications in emergency department flow, use of other services, or expansion of spaces (eg, surgical suites as ICU rooms or holding patients in floor halls) as solutions to the new issues we face.

In the emergency department, limiting the number of face-to-face interactions can be accomplished through the use of telehealth, which allows providers to remotely evaluate patients. Federal and state regulations have temporarily eased the guidelines to allow for appropriate deployment of providers in areas of high demand. 

The technology component may be the easiest to address, as there are many vendors that offer virtual meetings and products that allow for audio and video interactions that do not compromise the quality of the evaluation. For quick implementation, consider the least complicated products, including those which are already in use in your hospital and familiar to staff for teleconferences, such as Zoom, Skype, and FaceTime. This model can potentially eliminate at least one face-to-face interaction, conserve PPE use, and reduce downstream risk to other areas of the hospital system and employees, so long as evaluations are conducted by an experienced provider. 

Some HCWs with experience in telemedicine and the least complicated and most cost-effective platforms are necessary to quickly and successfully implement a tele-triage program during this pandemic. Staffing can be accomplished internally or through outsourcing. Physicians who do not have experience with telehealth can be trained, especially those who qualify for medical exclusions (eg, quarantined but asymptomatic, immunocompromised, pregnant, older physicians, or those with underlying medical conditions). They can continue to work with minimal to no exposure and also minimize the impact to staffing issues during this critical time. Physicians, NPs, and PAs whose clinics are closed, retired physicians, surgeons with canceled elective surgeries, resident physicians, locums, volunteer physicians, and those physicians from areas that are only mildly affected can help. 

Emergency credentialing may be possible to allow other available physicians to provide needed assistance, and many states have introduced processes to expedite temporary licensing for the length of the pandemic (see the “50-State Survey: Temporary Medical Licensure Measures in Response to COVID-19” and ACEP’s reference on “Licensing and Credentialing”). CMS has waived licensing requirements for Medicare and Medicaid patients. Any physician licensed in any state is allowed to provide care to any Medicare or Medicaid patient in any other state of the United States during this declared emergency. However, for this federal waiver to be effective, the state also has to waive its licensure requirements, either individually or categorically, for the type of practice for which the physician or nonphysician practitioner is licensed in his or her home state.

Although emergency physicians are generally the most experienced in recognizing emergencies and can start patients on the correct path, allowing non–emergency medicine staff to work in tele-triage can help free up emergency physicians to care for more critical patients. Having backup staff in place, increasing call obligations to create two layers of backup, or redistributing HCWs based on need may also prevent emergency departments from being severely overwhelmed due to increased demand or insufficient manpower. Temporarily increasing shift hours from 8 to 12 hours or having a cohort staffing model (one/two-weeks-on and one/two-weeks-off) may also minimize the number of exposed HCWs. 

Wireless medical telemetry systems (WMTSs), such as VIOS, GE Healthcare, Edan, Medeia, and Phillips, can be used for real-time monitoring of patients. Platforms also available for rapid implementation include Zoom, Polycom/Cisco, Skype, FaceTime, Doxy.me, and other free apps. During this pandemic, we can afford to circumvent red tape and forego ideal conditions and equipment (eg, HIPAA-compliant software, tele-triage with peripherals, integration of the platform with the current EMR, virtual waiting rooms, multiple screen-facing workstations) to swiftly respond to the current needs. HIPAA will not be enforced during this public health emergency (see HHS’s “Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency” and ACEP’s notice on HIPAA). While software exists that can integrate EMRs with tele-triage platforms, using this software can be more expensive and can lead to delays in implementation. Using the existing EMR as a separate screen and long-in can save time and money.

Even with simple solutions, issues will arise, so frequent evaluations and a contingency plan that addresses issues involving equipment, software, charting, staffing, patients, and workflow can alleviate staff concerns. In the future, the model can be modified to comply with HIPAA, CMS, or regulatory bodies as well as the needs of the hospital, staff, and patients. Established tele-triage companies tend to be more costly but have more robust and flexible platforms, compliant models, refined software, and uninterrupted support for technology-related issues. A transition to this type of tele-triage service can be made whenever organizations are ready.

Tele-triage pathways and workflows should be as user-friendly and simple as possible, both for the patient and the physician. As physicians, NPs, and PAs start practicing tele-triage, they may benefit from following scripts and complaint-driven templates. Patients may benefit from an intuitive process where they follow colored tape on the floor or respond to screening questions on their phone to be directed to a care area. Social media, journals, FOAM, private communication interfaces, and the press can all be used to share communication about technological successes and challenges, as we refine our telehealth response to the pandemic.

Telehealth can also be used to assist with supervision of residents, NPs, and PAs. CMS is modifying the direct supervision requirements for physicians overseeing services delivered by nonphysician practitioners and for teaching physicians overseeing services performed by residents. For the duration of the COVID-19 emergency, the overseeing physician does not need to be in the same physical location as the nonphysician practitioner or resident providing the service, but instead can provide “direct supervision” remotely via telehealth with both audio and visual components.

Billing and reimbursement

This is a fluid situation as government and private payers evaluate telehealth payment policies as we work through the crisis. As of March 30, CMS has added the emergency department E/M codes (CPT codes 99281-99285), the critical care codes (CPT codes 99291 and 99292), and the observation codes (CPT codes 99217-99220, 99224-99226, and 99234-99236) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency. When delivering emergency telehealth services, emergency physicians should use the code that most accurately reflects the service being performed and use the same place of service code that they would have used if that service was delivered in person. They should also attach modifier 95 to the claim. For example, regardless of location, emergency physicians who are delivering emergency services can use the emergency department E/M codes and attach modifier 95. Telehealth services must have both an audio and visual component. The emergency physician can be located in the emergency department, on the hospital “campus,” or providing the care remotely (from any location). 

During this declared emergency, we can reduce or waive the Medicare patient’s copay, if we so choose, for telehealth encounters. CMS has waived the requirement to collect cost-sharing from Medicare beneficiaries at this time. Additionally, telehealth can be provided in rural and urban areas with no location restriction.

Some private insurance companies may not allow the use of emergency department E/M codes for telehealth. In such cases, consider billing previously CMS-approved services, such as the office/outpatient E/M services (CPT codes 99201-99215), psychiatric diagnostic evaluations (CPT codes 90791-90792), psychotherapy for crisis (CPT codes 90839-90840), and critical care consult G-codes (HCPCS codes G0508-G0509). 

This quick guide is just that, a guideline, and should be adjusted to the particulars of each site. Telehealth can and should be used for all members of the health care team, whenever it is reasonable to do so, to help protect everyone, not just physicians. Knowing the laws, rules, and position of your individual organization can help, but do not ignore your own judgment, intelligence, knowledge, common sense, and understanding of medicine and patient care. Most importantly, “do no harm.” Frequent communication is essential, and each area of the health care model must be represented (ie, medical director, nursing director, registration, security). Always assess and reassess situations, make mental notes of ways to refine processes, and make leaders aware so that timely changes can be made.

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